1. health and fitness
2. disease

Take the Shock Out of Sepsis
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Program Overview:
Simulation Workshop
Didactic content
review
Documentation and
policy review
(hospital-specific)
Simulation scenarios
(4) and debrief
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Metrics: Sepsis Program
 51% Increase in
Tested Knowledge
 49% Increase in
Consistency
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Sepsis Quality Initiative Program
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Epidemiology
•Sepsis is the leading cause of death for
critically ill patients in the United States
•It is the tenth most common cause of
death overall
•It accounts for 1-2% of all hospitalizations
and for 25% of ICU bed utilization
• Projection for 2020 is 1,100,000 new
cases of sepsis
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Patient Safety and
Quality Costs
Sepsis: $50,000 average cost to treat one septic
patient1
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Sepsis: Progression
Infection
Neutrophil
activation
and TNF
release
hypotension
Vasodilation
Edema and
hypovolemia
Increased
microcoagulation
begins to be
excessive
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Decreased
tissue
perfusion
Damaged
vascular
endothelium
Organ
failure
Mortality
As sepsis progresses, mortality
increases
20% for sepsis
40% for severe sepsis
Greater than 60% for septic shock
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Sepsis Continuum
SIRS
• A physiologic response of the
endocrine axis and immune systems
Sepsis
• SIRS + a known or suspected infection
Severe
• Sepsis + acute organ dysfunction
Sepsis
Septic
Shock
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• Severe sepsis + refractory hypotension
SIRS
•Systemic inflammatory response to a variety
of clinical insults
•The response is manifested by two or more of
the following variables:
Clinical
• HR
> 90 beats/minute
• Temperature < 36◦ C or > 38◦ C
• Tachypnea > 20 breaths/minute, or PaCO2 < 32 mmHg
Laboratory
• WBC < 4,000 or > 12,000/mm3 or > 10% immature
neutrophils (Bands)
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Sepsis
•Infection plus systemic manifestations of
infection
•In order to identify sepsis early it is
important to assess the patients history and
evaluate their index of suspicion
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Sepsis: Index of Suspicion
•Extremes of age (<10 years and >70 years )
• Primary diseases
Liver cirrhosis
Alcoholism
Diabetes mellitus
Cardiopulmonary diseases
Solid malignancy
Hematologic malignancy
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Sepsis: Index of Suspicion
•Major surgery, trauma, burns
•Invasive procedures
•Recent or prolonged hospitalization
•Prior antibiotic therapy
•Other factors such as childbirth, abortion, and
malnutrition
•Neutropenia
•Immunosuppressive therapy
•Corticosteroid therapy
•Intravenous drug abuse
•Compliment deficiencies
•Absence of spleen
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Severe Sepsis
Sepsis plus sepsis-induced organ
dysfunction or tissue hypoperfusion
Associated organ dysfunction is manifested
by:
•PaO2/FiO2
< 280
•Elevated lactates
•Oliguria (urine output < 0.5 ml/kg for at least 1
hour following adequate fluid resuscitation)
•Acute mental status alteration
•Hypotension –SBP < 90mmHg or a reduction in
SBP of at least 40mmHg from baseline
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Severe Sepsis: Signs,
Symptoms, Measures
•Hypotension
•Lactic acidosis
•Increasing serum creatinine
•Decreasing platelet count
•Increasing PT and INR
•Increasing ventilation requirements
•Widened anion gap
•Decreasing Pulses
•Decreasing ScvO2
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Septic Shock
Sepsis-induced hypotension
persisting despite adequate fluid
resuscitation
Minimally responsive to volume loading
which will actually increase lung water
contents
Treatment requires volume replacement
and vasopressors
May require hormonal stimulation
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Septic Shock:
Clinical Findings
•Persistent Hypotension
•DIC
•Coma
•ARDS/Pulmonary edema
•Oliguria/azotemia
•Hypoglycemia
•Leukopenia
•Ischemia
•GI Bleeding
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Impacting Mortality
•Improve recognition and rapid
interventions
•Implement Sepsis Bundles
•
Resuscitation Bundle
•
Management Bundle
•Eliminate source of infection
• Evaluate and resuscitate tissue perfusion
•Appropriately support the organs
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Sepsis Resuscitation
Bundle
Complete within the first six hours of
identification
Diagnose:
Measure serum lactate
Obtain blood cultures prior to antibiotic
administration
Treat:
Administer broad spectrum antibiotics within 3
hours of ED admission and 1 hour of non-ED
admission
In the event of hypotension and/or serum lactate >
4mmol/L:
• Deliver
an initial minimum of 20ml/kg of crystalloid or an equivalent
• Apply vasopressors for hypotension not responding to initial fluid
resuscitation (MAP > 65mmHg)
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Surviving Sepsis Campaign
Guidelines
Blood pressure support
Fluid therapy
• Begin fluid administration immediately for sepsis
related hypotension or lactate > 4mmol/L
• Give a fluid challenge of 20ml/kg crystalloid or 300500 ml of colloids over 30 minutes. More rapid or
larger volumes may be required for sepsis induced
tissue hypoperfusion
Target a MAP of ≥ 65mmHg
Target a urinary output of ≥ 0.5ml/kg/hr
Consider placing a central line with oximetry capabilities
• Target CVP 8-12 cmH2O in non-ventilated patients and
12-15 cmH2O in ventilated patients
• ScvO2 ≥70%
• SvO2 ≥ 65%
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Surviving Sepsis Campaign
Guidelines
Infection Diagnosis
Identify source within first six hours of
sepsis.
Use physical exam, imaging and
preliminary culture results to determine
source.
Obtain cultures from all pertinent sources
prior to antibiotic therapy.
Do not allow a significant delay in
antibiotic administration due to obtaining
cultures.
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Sepsis Management
Bundle
Complete within the first 24 hours of
identification
Administer low-dose steroids for septic shock in
accordance with a standardized ICU policy. If not
administered, document why the patient did not qualify
for low dose steroids based on the standardized policy.
Maintain glucose control: Treat blood sugar >180 and
keep ~150
Administer recombinant human activated protein C
(rhAPC) [dortrecogin alfa: Xigris®] in accordance with a
standardized ICU policy. If not administered, document
why the patient did not qualify
Maintain a median inspiratory plateau pressure (IPP) <
30cmH2O for mechanically ventilated patients using lung
protective strategies.
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Surviving Sepsis Campaign
Guidelines
Steroids
•Do
not use in the absence of shock unless
patients endocrine or corticosteroid therapy
warrants it.
•Increases vascular tone and response to
vasopressors
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Surviving Sepsis Campaign
Guidelines
Intensive insulin therapy
Aim to keep blood glucose ~150 mg/dL
using a validated protocol for insulin dose
adjustment
Provide a glucose calorie source and
monitor blood glucose values every 1-2
hours in patients receiving IV insulin
•Every 4 hours when stable
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Surviving Sepsis Campaign
Guidelines
rhAPC [dortrecogin alfa: Xigris®]
Improves microcirculatory perfusion in
severe sepsis by decreasing inflammation,
decreasing coagulation and increasing
fibrinolysis
Replaces endogenous activated protein C
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Surviving Sepsis Campaign
Guidelines
Recombinant Human Activated Protein C
(rhAPC)
•Anti-inflammatory
properties
•Anti-thrombotic properties
•Pro-fibrinolytic properties
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Surviving Sepsis Campaign
Guidelines
rhAPC [dortrecogin alfa: Xigris®]
Must be administered in an isolated lumen
Discontinue 2 hours prior to invasive
procedures or those at an inherent risk of
bleeding
Restart 12 hours after major invasive
procedures or 2 hours after less invasive
procedures
Potential for antibody development
Only good for 12 hours after preparation
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Surviving Sepsis Campaign
Guidelines
Mechanical Ventilation
The goal of low tidal volume ventilation for
septic patients with acute lung injury (ALI) and
acute respiratory distress syndrome (ARDS) is
to reduce injurious lung stretch and release of
inflammatory mediators
Target tidal volume of ≤6ml/kg of predicted
body weight
Target initial upper limit of plateau pressure ≤
30 cmH2O
Allow PaCO2 to rise above normal to minimize
tidal volume and plateau pressures
Use peep to avoid alveolar collapse
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Surviving Sepsis Campaign
Guidelines
Additional Therapies
•Prophylaxis for DVT
•Stress ulcer prophylaxis
•Prevention of nosocomial pneumonia by
elevation of head to 45 degrees
•Use daily sedation interruption to facilitate
early wean and extubation
•Narrow antibiotics when appropriates
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Conclusion
Open for discussion and
question
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